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EXPOSURE HISTORY
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Have you ever smoked or used tobacco? (Please click if yes)
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What form(s)? (Select all the apply).
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If other, please explain:
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How often (number/per day)?
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If/when you smoke(d), how long did you smoke (years)?
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If you quit smoking, how long has it been (years)?
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Do you use any of the follow?
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Do you travel a lot?
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If yes, how many airplane miles annually?
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Do you consider your job stressful?
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If stressful, can you rate it?
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What do you do for work?
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What is the physical demand level of your job?
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Please select if you've had exposure to radiation, harmful chemicals, or pesticides.
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Please list the exposure types and dates.
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Do you use hot tubs, saunas or jacuzzi's?
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If yes, how often?
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Exercise?
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Exercise?
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Patient's Diet
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Patient's diet
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In addition, do you have (or have you ever had) any of the following?
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REVIEW OF SYSTEMS
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Do you have, or have you ever had, any of the following?
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Please Click if No to All
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Weight Loss?
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Chronic Fatigue?
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Weight Gain?
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Difficulty Sleeping?
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Migraines?
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Dizziness?
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Fainting?
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Cataracts?
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Glaucoma?
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Difficulty hearing?
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Vision Loss?
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Need Glasses?
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Wear Dentures?
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Asthma?
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Emphysema?
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Bronchitis?
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Tuberculosis?
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Shortness of breath?
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Cough up blood?
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Chest Pain?
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Heart Attack?
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Heart Arrhythmia?
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High Blood Pressure?
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High Cholesterol?
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Deep Vein Thrombosis?
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Poor Appetite?
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Nausea?
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Vomiting?
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Diarrhea?
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Constipation?
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Ulcerative Colitis?
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Crohn's Disease?
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Irritable bowel syndrome?
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Bloody Stools?
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Difficulty Urinating?
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Pain/Burning?
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Blood in urine?
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Incontinence?
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Kidney Stones?
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Urinary Tract Infection?
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STDs?
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Joint pain/Stiffness?
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Difficulty walking?
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Muscle Pain?
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Herniated disc?
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Back Injury?
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Stroke?
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Seizures?
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Numbness?
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Anemia?
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Bleeding Problem?
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Blood transfusions?
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Anaphylaxis?
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Autoimmune Disorder?
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Thyroid Disease?
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Adrenal Disease?
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New Moles?
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Breast mass/pain?
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Breast Discharge?
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Depression?
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Memory Loss?
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Panic Attacks?
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Anxiety?
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GAD-7
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Over the last 2 weeks, how often have you been bothered by the following problems?
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Feeling nervous, anxious, or on edge
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Not being able to stop or control worrying:
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Worrying too much about different things:
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Trouble relaxing:
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Being so restless that it's hard to sit still:
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Becoming easily annoyed or irritable:
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Feeling afraid as if something awful might happen:
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If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get
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Scoring
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Family History
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Is there a family history of any of the following?
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Other
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Any additional info to be noted:
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